View the varicella-zoster virus (VZV) depicting the latency of VZV.
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Dr. Charles Cefalu’s insights on zoster
My colleagues and I expect that the number of cases of zoster that we see in our practice will increase as the population ages. In the United States, approximately 1 million cases of zoster are diagnosed a year. There’s not only a growing number of patients over 60 thanks to the aging baby boom population, but elderly patients are living longer, and living with other chronic illnesses that tax their immune systems and put them even more at risk for zoster and its complications.
Zoster symptoms can include significant pain and discomfort. Additionally, though for most people the pain of zoster lessens as the rash heals, zoster can progress into postherpetic neuralgia (PHN), which can result in some of the most excruciating pain a person can experience.
PHN patients may require narcotics to manage the unrelenting pain. They can become depressed and require anti-depressants, which can produce complicating side effects and other drug interactions, especially if the patients are being treated for co-morbid illnesses—which they often are.
I’ve had patients forced to quit working because of the pain and multiple medications that can seriously compromise the ability to work and live a productive life.
As family physicians, I think it’s becoming more important for us to understand that many millions of people in the United States are becoming increasingly at risk for zoster as they age. It’s time for us to be more alert to the potential for zoster when elderly patients present with nondescript pain, because early diagnosis and treatment with antivirals can help reduce the duration of both the acute and chronic pain of zoster.
Dr. Andrew Weinstein’s insights on zoster
I see zoster as a growing public health concern. Every year that a person is alive increases his or her chance of getting zoster. And, as the population ages, the sheer number of people at risk for zoster will as well. I see advance notice of this trend because of the large number of retirees in my community in Palm Beach County.
Even the best clinician can miss zoster in the prodromal stage. Zoster can easily be mistaken for one of the many eruptions it can mimic. When a patient comes in complaining of a nonspecific ache or pain, or unilateral discomfort that he or she finds hard to describe, we have to start thinking about the possibility of zoster. The primary eruption of zoster can last up to 30 days. For most people, the associated pain diminishes as the skin improves.
In addition to the common presentations of herpes zoster: grouped vesicles in a linear array, less frequent but potentially serious complications may occur. For example, I recently treated a case of zoster complicated by cutaneous vasculitis. The secondary vasculitis resulted in ulcers on his buttocks and genital area. As a result of the location and severity they became infected. It was so severe that he couldn’t sit down for a week. We started treatment, antiviral therapy, corticosteroids and antibiotics. Luckily he recovered with minimal long-term damage.
Most physicians are aware of the potential complications of zoster, but if they haven’t seen any in practice first-hand, they may be unaware how severe zoster-associated complications can be. Depending on the anatomical location, zoster can lead to visual and hearing impairment, among other things. Even an apparently innocuous case of zoster can result in permanent discoloration and scarring of the skin where the vesicles occurred.
One of the most serious complications of zoster is postherpetic neuralgia or PHN in which inflamed nerve fibers cause chronic, often debilitating pain. For patients with PHN, it is possible for the skin to remain painful and sensitive to the touch for years after the exanthem diminishes.
Allodynia is a common manifestation of PHN. Patients will experience pain resulting from a non-noxious stimulus to normal skin. One of the most serious cases I have seen in my practice is a gentleman in his 70s. His zoster presented along the first and second branches of the trigeminal nerve and progressed to allodynia. As a result, the slightest stimulus to the right side of his face causes him to feel horrible pain.
This understandably makes simple everyday tasks challenging for my patient. He can’t shave. He can’t scratch his face. Even the wind blowing across his skin is extremely painful. So as a result, his spouse has had to become his caregiver.
In my opinion, making an accurate diagnosis early is key to managing zoster and its complications.
Dr. Edgar Ross’ insights on zoster
At the Pain Management Center at Brigham and Women’s Hospital, we see about 23,000 patients a year, and among those patients, an increasing number of cases of zoster. Many physicians and patients think of zoster as a dermatological problem. But in our pain management center, we see herpes zoster patients whose disease may have progressed to significant neuropathic pain and complications. From a neurologic perspective, zoster can be considered a serious problem; and as the patient population ages, we need to actively address this disease.
Shingles, in the prodromal phase, can be very painful. For most people, the pain of zoster lessens as the rash heals. In some cases, however, zoster can progress into postherpetic neuralgia, or PHN. Some patients who develop PHN can develop severe pain that becomes their overwhelming life focus. The patients I see are healthy, active older people, but sometimes, when they develop PHN, their lives change, they may become homebound, depressed—essentially disabled. Though they may have been independent, now they have to rely on a caretaker.
Through my practice at the Pain Management Center I’ve seen some very severe cases of zoster. For example, I treated a woman with Ramsay Hunt Syndrome (postherpetic neuralgia of the sixth cranial nerve). She suffered from severe ear pain, she couldn’t comb her hair and she couldn’t go outside because even a mild breeze across the ear became excruciatingly painful for her.
On a personal level, my mother-in-law developed shingles (in the cervical area) and experienced hemi-diaphragm paralysis. The paralysis affected her for years, decreasing her ability for aerobic capacity because only half of her diaphragm was working.
For zoster patients who develop PHN, the best we can do is to try and manage the pain. Opiates are almost always involved, but opiates themselves are not enough. Polypharmacy may be required to get the pain under control, with analgesics, topical agents and anti-convulsants. We can stop other pain-related disorders from occurring, or at least decrease their frequency, and patients know that there is an end point. With PHN there is potentially no end point. It can be unremitting. Patients can take medications that help but then they may experience cognitive impairment or sedation.
The virus that causes zoster and zoster-associated pain change the physiology of the nervous system, potentially leading to nerve damage and permanent central sensitization.
